The role of ERAS society

The role of
Olle Ljungqvist MD PhD
Professor Surgery
Örebro University Hospital & Karolinska
Institutet
Sweden
Improving Perioperative Care Worldwide

VERBAL DISCLOSURE
• Co-founder ERAS Society
• Founder, stock owner Encare AB
• Advisor Nutricia A/S The Netherlands
• Advise Abbot, USA & Merck, USA
• Speakers honoraria: Fresenius-Kabi, BBraun,
Nutricia, Nestle, Merck

Variations between countries
Risk of death after surgery
Pearse R et al Lancet 2012; 380: 1059-65

2010
0
5
10
15
20
25
Colectomy:Mean LOS by Provider Oct - Dec 2010
Provider Organisations
Meanlengthofstay(days)
Source: Hospital Episodes Statistics (Provisional)
Variations in a single country
Courtesy M Scott

7
UCL
LCL0
10
20
30
40
50
60
70
80
1
4
7
10
13
16
19
22
25
28
31
34
37
40
43
46
49
52
55
58
61
64
67
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214
217
LengthofStay(Days)
Patient Number
Kelowna General Hospital Colorectal Patient Length of Stay Starting 3/09/2010
UCL: 32.3
UCL: 10.3
Pre-ERACS
Mean
12.8
ERACS Mean
ERACS Introduction
ERAS Reduce Variation in Outcomes
in a single hospital
Coutersy Dr R Collins, Kelowna, B.C.

ERAS Society
A quick history and what we learned

2001
Olle Ljungqvist Ken Fearon
Preop Carbohydrates Cancer Cachexia

Started in 2001
Collaboration
Grew over time
Several studies
Tromsö: A Revhaug
Stockholm: O Ljungqvist
Copenhagen: H Kehlet
Maastricht: M v Meyenfeldt, C deJong
Edinburgh: KFC Fearon
2010 ERAS Society
ERAS Study Group

Review of the literature
Compare with our own practice
ERAS Study Group

Not aligned – very different
Move all to ERAS care
Audit of the process
ERAS Study Group

The next surprise
Not what we believed
ERAS Study Group

The next surprise
Not what we believed
Audit to get control
ERAS Study Group

ERAS
Epidural
Anaesthesia
Prevention
of ileus/
prokinetics
CHO - loading/
no fasting
Early
mobilisation
Peri-op fluid
management
DVT
prophylaxis
Pre-op
councelling
Short acting
anestetics
No - premed
No bowel prep
Perioperative
Nutrition
Body heating
devises
Oral analgesics/
NSAID’s
Incisions
No NG tubes
Early removal
of catheters/drains
Fearon et al, Clin Nutr 2005

First experience
ERAS Implementation NL
Gillissen et al, World J Surg 2013

Why ERAS Society?
We had a better care plan
We could teach others
Interest was growing
Networking society

A Non profit Multi-professional Multi-disciplinary
Medical Society
Founded in 2010
Mission statement: Enhancing Recovery After Surgery
The mission of the Society is to develop perioperative care
and to improve recovery through
• Research,
• Education,
• Implementation of evidence based practice.
• Audit
Improving Perioperative Care Worldwide

Do the guidelines work?
A test of Compliance

ERAS® compliance:
Length of stay & Readmissions
Gustafsson et al, Arch Surg 2011
n = 953
p < 0.05
Compliance with ERAS protocol elements
Colorectal cancer

ERAS® compliance:
Complications
Gustafsson et al, Arch Surg, 2011
n = 953
p < 0.05
0
5
10
15
20
25
30
35
40
45
50
<50% >70% >80% >90%
Complica ons
Percentpatientsaffected
Colorectal cancer

ERAS® compliance:
Complications 13 hospitals 7 countries
ERAS Compliance group Ann Surg, 2015
n = 2352
Multi center study, consecutive patients
Percentpatientsaffected
Colorectal cancer
0
10
20
30
40
50
<50% 75-90% >90%
Major complication
Any complication

ERAS® compliance:
5 year mortality
Gustafsson et al, WJS 2017
5yearoverallmortality
<70% >70%
Postop days
42% risk reduction, p<0.001

Colorectal
Pancreatic resection
Cystectomy
Gastrectomy
2015: Anaesthesia
2015/16: Gynecology
2016/17: Bariatric
H & N cancer
Breast reconstruction
Liver resection
Nephrectomy
Hip replacement
Knee replacement
Thoracic
Esophageal resection
ERAS® Society Guidelines

Colorectal
Pancreatic resection
Cystectomy
Gastrectomy
2015: Anaesthesia
2015/16: Gynecology
2016: Bariatric
H & N cancer
Breast reconstruction
Liver resection
Nephrectomy
Hip replacement
Knee replacement
Thoracic
Esophageal resection
ERAS® Society Guidelines

ERAS 2005
Securing modern care: colon resection
Surgeon:
No bowel prep
Food after surgery
No drains
Early removal u-
catheter
No iv fluids, no lines
Early discharge
All evidence based!
Anesthetist:
Carbohydrates no fasting
No premedication
Thoracic Epidural
Anesthesia
(open)
Balanced fluids
Vasopressors
No or short acting
opioids
Nursing:
Structured preoperative
information
Preop CHO
Remove Iv lines and
drains
Support mobilisation
Serve normal food
Follow up

ERAS flow chart
Pre admission
nutritional support
Cessation of smoking
Control alcohol intake
Medical optimization
Preoperative
information
Selective
Bowel
preparation
Preoperative
carbohydrates
No NPO
PONV
prophylaxis
Minimal invasive surgery
Minimize drains and
tubes
Regional analgesia
Opioid sparing anesthesia
Balanced fluids
Temperature control
Early removal of
drains and tubes
Stop iv fluids
Multimodal opioid
sparing pain control
Early mobilization
Early oral intake of
fluids and solids
Post discharge follow
up
Pre admission Preoperative Intraoperative Postoperative
Surgery
Anesthesia
Nursing
Ljungqvist, Scott, Fearon, JAMA Surgery, 2017 152(3):292-298

Seefeld 2013: ≈ 100 colorectal specialists & SAGES USA 2014 ≈ 250 surgeons
Hong Kong 2016: 1500 anesthesiologists
Who is aware of ERAS?
Martin Hübner 2013, O Ljungqvist/ L Feldman 2014, Ljungqvist 2016
ERAS obstacle – wish vs. reality

Who has an ERAS protocol?

Who could provide data on compliance?

ERAS
Epidural
Anaesthesia
Prevention
of ileus/
prokinetics
CHO - loading/
no fasting
Early
mobilisation
Peri-op fluid
management
DVT
prophylaxis
Pre-op
councelling
Short acting
anestetics
No - premed
No bowel prep
Perioperative
Nutrition
Body heating
devises
Oral analgesics/
NSAID’s
Incisions
No NG tubes
Early removal
of catheters/drains
Anaesthesia

ERAS
Epidural
Anaesthesia
Prevention
of ileus/
prokinetics
CHO - loading/
no fasting
Early
mobilisation
Peri-op fluid
management
DVT
prophylaxis
Pre-op
councelling
Short acting
anestetics
No - premed
No bowel prep
Perioperative
Nutrition
Body heating
devises
Oral analgesics/
NSAID’s
Incisions
No NG tubes
Early removal
of catheters/drains
Anaesthesia
Surgery

ERAS
Epidural
Anaesthesia
Prevention
of ileus/
prokinetics
CHO - loading/
no fasting
Early
mobilisation
Peri-op fluid
management
DVT
prophylaxis
Pre-op
councelling
Short acting
anestetics
No - premed
No bowel prep
Perioperative
Nutrition
Body heating
devises
Oral analgesics/
NSAID’s
Incisions
No NG tubes
Early removal
of catheters/drains
Anaesthesia
Surgery
ORPreop
PACU/ward

ERAS
Epidural
Anaesthesia
Prevention
of ileus/
prokinetics
CHO - loading/
no fasting
Early
mobilisation
Peri-op fluid
management
DVT
prophylaxis
Pre-op
councelling
Remifentanyl
No - premed
No bowel prep
Perioperative
Nutrition
Bairhugger
Oral analgesics/
NSAID’s
Incisions
No NG tubes
Early removal
of catheters/drains
Fearon et a al 2005, Lassen et al Arch Surg 2009

Local Leadership Team
Anaesthesiologist Surgeon ERAS Coordinating Nurse

ERAS team approach
• Surgeon
• Anesthestist
• HDU specialist
• Ward nurses
• Anesthesia nurses
• Physiotherapist
• Dietitian
• Management
Team work:
• Training
• Implementing
• Planning
• Auditing
• Updating
• Reporting
• Research

ERAS® Interactive Audit System

ERAS Implementation plan
S 1
26-27 sept 2011
Introduction to
ERAS
Present status
Start data entry
Strategies for
implementation
Active work periods
S 2
28-29 nov 2011
Report of
Results (pre ERAS)
Goals, measures &
Outcomes
Planning for local
ERAS implementation
S 3
2 feb 2012
Video follow-up
Reporting results
S 3
7maj 2012
New situation
Reporting results
Summary of what has
Been learned
Planning for
the future
Successively start
using ERAS in patients
Work group meetings,
develop a new way of
auditing
Support by the Coach
Preparations Follow-
up
Alumni
Develop methods to
enter data into EIAS
Work group meetings
Dec 2011j-
Jan 2012
Half day
visit by
EIP-coach
Routine use of ERAS
for all patients
Work group meetings
for regular interactive
audit
4 Interactive work shops over 8 – 10 months
3 active working periods at home

ERAS Implementation
ERAS Center of Excellence (KOL)
ERAS Symposia & other local events
ERAS Implementation Program
New surgical disciplines; Colorectal,
Orhopedics, Gynecology, Urology etc.

ERAS in the world today
Castiglione, S.A. & Ritchie, J.A. (2011). Moving into action: We know what we want to change, now what?
An implementation guide for health care practitioners. Canadian Institutes of Health Research.
Courtesy F Carli
My view

ERAS August 2017:
Where are we?

49
ERAS®Society 2010
A few leading academic centers forms the Society
More than one Implementation program
ERAS Center in place
ERAS center discussions
Implementation program running/announced
ERAS center in training

50
ERAS®Society 2012 Cannes
a few ERAS centers, implementation just starting
ERAS center established in 2012

51
ERAS®Society May 2014
Growing…
ERAS center established

52
ERAS®Society growth in 2016/2017
100+ units in 20+ countries
ERAS center in training
Manilla
Singapore
Guadalajara
Bogota
Lisbon
Tokyo
Nanjing, Bejing
Krakau
Cape town
Buenos Aires
Auckland
Mayo Clinic
Alberta HS
Hamburg
CT, Charlotte
Soeul
Sao Paolo
Porto Allegro
Ankara
Groningen
Tel Aviv
Teheran
Santiago
Montevideo
RomeERAS USA
Melbourne

USA ERAS® Implementation Program
Before ERAS® Implementation Program
After ERAS® Implementation Program
Fewer complications
Fewer readmissions

First experience & Sustainability
ERAS Implementation NL
Gillissen et al, World J Surg 2013

Poor Sustainability
Compliance after ”project”
Gillissen World J Surg (2015) 39:526–533

Poor Sustainability
Longer LOS despite more MIS
Gillissen World J Surg (2015) 39:526–533

6 years of ERAS & audit
Training
Continuous Team work & audit

ERAS & Cost savings single units
• New Zealand – $4,500
– 4,000€ / patient in the first 50 patients. Study
visits & full time included
• Switzerland - $1,650
– 1,500€ / patient per first 50 patients. Training &
full time nurse included
• Canada - $2,985
– 2985 $/ patient (colorectal surgery)
– 2,200 €/ patient (esophageal surgery).
Roulin et al, BJS 2013, Sammour NZJS 2010, Lee BJS 2013, Lee Ann Surg 2014
S Africa: ≈20% uncomplicated
≈24% complication
R Oodit, personal communication

2.4 – 5.1 Return on Investment
Thanh et al, Can J Surg 2016

Research developments
• Already more than 25 studies published on
the systems (15 in the last year)
• Research Support Unit – Audit System data
• Audit studies – 40,000 patients
• Prospective studies
• Örebor University & Industries

ERAS® Experiences
• Issues are similar everywhere
• Variation in delivery
• Variation in outcomes
• Poor control of the entire process
• Pressure for better results at lower cost
• Very similar model works everywhere
• ERAS team work
• Audit
• Continuous improvement work
• Cost saving

ERAS® Society role
• Gather expertize and develop guidelines
• Multi professional – multi disciplinary
• Guidelines
• Platforms for
• Education
• Meeting places – congress – regional - national
• Implementation – via Centers of Excellence
• Research – ERAS Audit database

The role of ERAS society

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